A critical examination of health system governance in Nunavut

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Gwen Healey is the Executive and Scientific Director of the Qaujigiartiit Health Research Centre in Iqaluit, Nunavut, and Assistant Professor at the Northern Ontario School of Medicine. She was born and raised in Iqaluit, Nunavut, and continues to live and work in her beloved home of Iqaluit.

Truly understanding, and taking action on, health challenges experienced in our communities requires us to be critical of the models that are conventionally used, to challenge the dominant narratives on the origins of health inequities in our communities, and design systems that reflect the worldview of our communities. Addressing health problems in Nunavut should be no different. There are two main problems with the health care system in the territory: governance and the model on which health care is based.

In Nunavut the governance and implementation of the health care system is encapsulated entirely within the Government of Nunavut. There is no meaningful community-level input into our health care. There is no meaningful regional-level governance of our system because the regional health boards, which once existed, were eliminated when Nunavut was formed. There is no independent oversight of our hospital or health centres, whereas in most jurisdictions in Canada, hospitals have independent governing boards. Our hospital and health centres are all governed by the Department of Health, as part of a carry-over from the nursing station model implemented in the 1950s, which still exists in rural regions in Canada. Therefore, there are no formal avenues for Nunavummiut to have input into our health care system unless one contacts one’s Member of the Legislative Assembly or the Minister of Health. The end result is that if one has an opinion about a process or a protocol or a policy or treatment in our health care system, there is no independent board or authority to inform or to turn to for advice. Without independent layers of oversight and accountability, how can our system function? How can this system meet the needs of our communities when we are not permitted to participate in its oversight and implementation? A return to a board governance structure could address this significant gap in the current health care system.

And then there is the biomedical care model on which the health system is based. Current biomedical models operate under the assumption that illness is secondary to disease, i.e. that we are sick because a disease is making us sick. Therefore, if one treats the disease, the illness will disappear as well. The biomedical model is one of the dominant health care models around the globe. In recent years, indigenous health care models have been developed and increasingly recognized and implemented in New Zealand and Alaska.

Indigenous wellness perspectives are formulated on understandings of the world, which are based on interactions between people, as well as interactions with the land, animal, and spirit worlds. Illness may originate from a place of disharmony rather than simply disease of the body, and wellness can be achieved by restoring balance, both emotional and spiritual, as well as treatment of a physical ailment. This differs from the common biomedical practice of focusing on the individual in isolation, outside of the individual’s place in society or connection to the land, animal, and spirit worlds. The biomedical model fails to capture this and other important perspectives related to what Nunavummiut feel we need to be well. Today, the tension between western biomedical models of health care provision and Inuit wellness models of care continues to permeate all facets of our health system. This tension is not new, and has been highlighted in indigenous communities throughout Canada and the globe.

There are a number of successful examples of health system models that have been developed to meet the needs of the populations they serve. In New Zealand, for example, the Maori Ministry of Health developed a health strategy based entirely on Maori conceptions of well-being, the result of which was a multi-faceted approach to health care delivery which placed Maori families, extended families, and kinships at the centre in a holistic model. In a series of case studies, they have shown how their approach has led to significant improvements in Maori health, for example in increased immunizations rates and cervical cancer screening.

In Southcentral Alaska, the “Nuka System of Care” is the name given to the health care system which was created, managed, and owned by Alaska Native people to achieve physical, mental, emotional and spiritual wellness. The relationship-based Nuka System of Care is comprised of organizational strategies and processes; medical, behavioural, dental, and traditional practices; and supportive infrastructure which work together – in a collective relationship-based framework – to support wellness. By putting relationships at the forefront of what they do and how they do it, the Nuka System was designed to meet the immediate needs of their communities as well as to continue to develop and expand for future generations.

The creation of Nunavut was about self-determination and self-governance. The health care system is an important part of self-determination and health care systems can and should mirror the values of the people they serve. In Nunavut, such a system should be embedded in a health care model that is grounded in Inuit ways of knowing and understanding wellness. Such models are a critical part of on-going self-determination and decolonization processes for indigenous communities throughout the Arctic and around the globe.

As a small territory, we have an opportunity to be innovative, creative, and solution-seeking in our health system governance and implementation. Nunavut is not a ‘challenge to be met’ – our territory is an opportunity to embrace. We have strengths, we have capacity, and we are capable. We know and understand the pathways to wellness that work for our people, and we should build on them to implement a health care system that can meaningfully address our health outcomes. We can be global leaders in the creation of a health care system designed for and governed by Inuit.

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Declan Fox

Indeed. But surely not limited to Nunavit? The biopsychosocial model is the predominant one in UK primary care—tho has less influence in Canada—and while far from perfect, it is a reasonable model for placing the individual in his or her social, psychological and spiritual milieu. No man/woman is an island. The gallbladder in bed 18 has long been discredited as anything other than an insult to physically-oriented specialists, sometimes richly earned.
An excellent piece and I hope it will influence thinking